Life and Death in the War Zone

An American combat hospital mobilized in Iraq faces a daily drama of wartime treatment.
Airing March 2, 2004 at 9 pm on PBS
Aired March 2, 2004 on PBS

Program Description

While other reporters were embedded in fighting units during the Iraq War, NOVA was covering the emergency medical response, living night and day with the doctors, nurses, and medics in a frontline Combat Support Hospital (CSH). The program captures a period of the conflict in April and May of 2003 when CSH units faced a deluge of injured Iraqi soldiers and civilians who had little support from their country's collapsed health-care system.

Transcript

Life and Death in the War Zone

PBS Airdate: March 2, 2004

NARRATOR: During the conflict in Iraq, the U.S. military could
claim at least one undisputed victory: wounded American soldiers survived their
combat injuries in record numbers. In Vietnam, one out of every four wounded
died. In Iraq, at times, the number would shrink to one out of seven.

Much of the credit goes to Combat Support Hospitals, or CASH units, which
provide state-of-the-art emergency medical care to the troops.

COLONEL JOHN POWELL, M.D. (Commander, 10th Combat Support
Hospital): The CASH evolved out of the MASH. I mean, most everyone has
seen that television show all over the world—MASH stands for Mobile
Surgical Hospital and CASH is Combat Support Hospital. The hospital itself is
really geared towards surgery, um, towards battlefield surgery.

NARRATOR: These advanced medical centers are transported in
containers and can be set up just about anywhere.

SERGEANT WRINKLE: Basically, what we're setting up is a 44-bed jump
package. It is a basic CASH, which is a Combat Support Hospital. Once a
casualty is injured on the battlefield they'll fly in via medevac. From the
ambulance they'll be brought here to our front door, which is our E.M.T. tent.

DOCTOR: Blood pressure seems to be normal.

SERGEANT WRINKLE: From that point they'll then go into our O.R., our
O.R.. ...they'll be prepped.

DOCTOR: That's a big hole, whatever the hell that is.

DOCTOR: My middle finger's what's holding it.

SERGEANT WRINKLE: They'll go into O.R. for surgery. From that surgery
they'll then turn around and go to our I.C.U.s, which is our intensive care
units.

NURSE: Okay, perfect.

SERGEANT WRINKLE: From that point, they'll then be medevaced and go back
to the United States.

NARRATOR: During the Iraq war, five CASHs were sent to the
region. One year later, NOVA looks back at the experiences of two of these
units.

They had trained to take care of over 200,000 Coalition troops. But what
they encountered would test their training and shake their beliefs in ways that
they could never have imagined.

DOCTOR: ...maybe two other civilians on the way in. They don't know
their status.

NARRATOR:Life and Death in the War Zone, right now on
NOVA.

NARRATOR: Five weeks before the start of the Iraq war: at
their base in Fort Carson, Colorado, the elite 10th Combat Support Hospital, or
CASH, has spent months preparing for a mission to attack Iraq through Turkey.
About 550 people, doctors, nurses, technicians & support staff, will uproot
their lives to face an unknown danger.

Colonel John Powell is commander of the 10th CASH. A doctor and a
paratrooper with a long combat resume, he's trained to practice medicine under
battlefield conditions.

COLONEL JOHN POWELL, M.D.: This CASH, is a 296 bed hospital, okay? It's
just like a mortar and brick hospital up on the hill, but everything is under
tentage. We have gynecologists, we have a dentist, we have a facial surgeon, we
have people who can take care of eyes. I mean, we have infectious disease
specialists, we have internal medicine physicians. We have to be able to do all
the same things that a regular hospital does. But surgery is our main focus,
'cause during battle time, that's the big piece we want to make sure we know
how to do.

NARRATOR: Powell's second in Command is Colonel Dave
Lounsbury. Based at Walter Reed Medical Center in Washington, Lounsbury is the
editor of the Army's combat medicine textbooks. Like most military doctors, he
joined the service to pay his way through medical school.

COLONEL DAVE LOUNSBURY, M.D.: If you had said to me, when I finished
medical school, that 24 years from now you'll still be wearing a uniform and in
the service of the Republic, I would have just howled with laughter. I had no
intentions whatsoever of making a career out of this—none.

FEMALE SOLDIER: Leave this BAND-AID® on for about 24
hours.

NARRATOR: These doctors and nurses normally work at military
hospitals, with jobs just like their civilian counterparts'. Now, on the eve of
war, they're supplied with more than just stethoscopes and scalpels.

Most have had limited experience handling any weapon since basic
training.

FEMALE SOLDIER: I'm getting an M16.

COLONEL DAVE LOUNSBURY, M.D.: What in the name of sweet Mary and Joseph
is a surgeon doing with a holstered nine-millimeter pistol? Why does an O.R.
nurse have an M-16 rifle? Incongruous? For sure it's incongruous. Do they feel
comfortable carrying a weapon? I think many of them do not—I, first and
foremost. I'm not quite sure I know which end of the pistol the bullet comes
out of. And I'm sorry you weren't here to see my target practice a couple of
weeks ago.

NARRATOR: The entire staff has to practice protecting
themselves against chemical warfare, at this point considered a real risk. They
are preparing to treat mass casualties on a contaminated battlefield.

Sergeant Christian Ramirez, a paramedic, is an expert in chemical and
biological weapons.

SERGEANT CHRISTIAN RAMIREZ: A lot of the doctors are very knowledgeable
about the effects of theactual agents, biological and chemical, and how
they react with the body. But as for actual hands-on training, they're not as
familiar as, like, soldiers of the CASH that are here on a permanent basis.
Now's the time to get them ready.

COLONEL JOHN POWELL, M.D.: I think the fear of the unknown's the worst
piece of it. And I think there's always, in the back of your mind, even though
this is a hospital, there's always the potential that something could happen to
the hospital, and we'd have some people in the hospital get hurt or even get
killed. And I know my children are very concerned about what's going on, and I
know my wife is, too.

NARRATOR: Sergeant Ramirez isn't worried about leaving his
family behind; he's married to another member of the 10th. The couple will be
going to war together.

SPECIALIST CHRISTINA RAMIREZ (Preventative Medicine Specialist):
We dated about four months, which is kind of short, but, we kind of...we've
been inseparable since we did meet, so...and we just went to the Justice of the
Peace for now. We hope to have a nice ceremony later, but since all this stuff
came up, then...

SERGEANT CHRISTIAN RAMIREZ: But when you stop to think about the reality
of, what can real...what can happen, it's...you don't want to go into that. I
mean, I don't want to get shot. I don't want her to get shot, you know? I don't
want any of my friends to get shot. I don't want to see, you know, 18-year-old
boys, coming in missing limbs, you know? Bleeding from bullet wounds, and...
But, at the same time, you know I do want to go. I'm scared, but it's not going
stop me. I'm, I have a mission, and that's my focus.

COLONEL JOHN POWELL, M.D.: Their training is complete. They know what
the briefings are about terrorism and about personal protection. And they know
how to get their MOP suits on. And they have been issued all the gear they'll
need to take with them. So basically, they're ready.

NARRATOR: But on the 3rd of March, after three months'
intensive preparation, the 10th CASH's mission is put on hold when Turkey
refuses access to American forces.

ARI FLEISCHER (White House Press Secretary): There's no question
that the Turkish approach would have been a preferable approach, but other
approaches are available. There are other options, from a military point of
view, and the President has every confidence that those other options will
indeed be militarily successful.

NARRATOR: The 10th is forced to watch the first advances on
television. Finally, the unit is assigned a new mission, to support the army
invading from Kuwait.

COLONEL JOHN POWELL, M.D.: Take your seats. Everybody's got questions
about the mission. So do I, okay? Everybody remembers Somalia and what happened
when you get a small group of people who are really determined to keep you out,
okay? Now, I suspect those folks are all right, that's home for them. It ain't
for us. All right? Thanks again for all your attention and for your smiles and
your patience.

NARRATOR: On the 30th of March, two weeks after the start of
the war, the 10th Combat Support Hospital leaves for the Gulf. Despite all
their preparation, what they encounter will be completely unexpected. In the
first two weeks of the war, it's already clear that U.S. casualties are
relatively light. As American troops take Baghdad on the 9th of April, there
have been 87 U.S. soldiers killed, and a few hundred wounded in action.

MALE SOLDIER: Turn round, kneel down.

NARRATOR: The survival rate for the coalition wounded is high.
For the first time, ceramic body armor is worn by most combat troops, and total
air supremacy means any casualties can be quickly evacuated.

News reports reveal the appalling conditions of the Iraqi health care
system. They have no power, no water, no drugs, and the morgues are
overflowing. The little that's left is taken by looters as law and order breaks
down.

While the 10th CASH waits in Kuwait, another Combat Support
Hospital, the 21st, based at Fort Hood, Texas, gets the order to
enter Iraq.

Even though Baghdad has fallen, skirmishes and ambushes are common along
the way.

CAPTAIN MICHAEL REYES: All right, my mission is to get you up north 100
miles, approximately 100 miles north of Baghdad, in a safe and sound manner, so
you can execute your mission. Cool?

NARRATOR: Major Chris Niles, an anesthesiologist, has left a
wife and two daughters back in Florida. He's relieved to finally have a
mission.

MAJOR CHRISTOPHER NILES, M.D. (Anesthesiologist, 21st Combat
Support Hospital): There's a lot of opportunity for us to do some good
to help the people here of Iraq, 'cause it looks like they've been just
brutalized and had no health care, no infrastructure. And I think there's going
to be a chance for us to really help a lot of people. So I'm definitely looking
forward to it, getting back and doing my job.

CAPTAIN DALLAS WALKER: All right, let's pray. Our gracious eternal
Father, at this time, we do need to call upon you to watch over each one of us.
For we have a long journey ahead, oh, Lord. And yet we understand that you have
already marked out that path for us. And for that we are eternally grateful to
you. God bless us. Protect us in your holy and precious name, Amen.

NARRATOR: Without any escort, the staff of the 21st
CASH heads for a captured airbase in Balad, northwest of Baghdad. The three-day
drive takes them through the heart of the recent fighting.

At rest stops, the CASH has its first contact with Iraqis, civilians
begging for food and water or trying to trade bundles of the local currency for
a dollar.

For Captain Suki Quattlebaum, a nurse, it brings back painful
memories.

CAPTAIN SUKI QUATTLEBAUM, R.N. (Ward Nurse, 21st Combat
Support Hospital):I was born and raised in Korea, right after the
Korean War, and things were very scarce. Water and food was very scarce. And
when I see these kids, they remind me of when I was growing up. I was doing the
same thing in the street, begging for food and water from G.I.s. And they were
nice enough to throw out chocolates and candies and water, and they just made
my day. So it gets very emotional when I see these kids. So my heart breaks
when I just pass by them without giving them anything, because I know that was
me. That was me.

MALE SOLDIER: All right. If you don't know, we're about to go through
Baghdad. If something were to happen, you need to be divided into two sections.
If we need to fire, this side will fire towards your side, and this side to
that side. Let's not crossfire. It's not a nice thing. All right? Keep your
KEVLAR® on, stay down, and hopefully nothing will happen. Stay
safe. God bless. Here we go.

NARRATOR: The 21st CASH is split into two units.
The smaller unit goes to northern Iraq, while the larger section will set up
here, at the Balad airbase.

The hospital is packed inside 48 milvans, or military containers. The CASH
has just three days to build a 44-bed hospital from what's inside them. As a
sandstorm whips up around them, they mark exactly where each tent will go.

The hospital will be made up of interconnecting tents and hard containers,
which fold out to form rooms and wards. Once everything is in the right place,
the priority is getting the emergency medical treatment sections set up.
Medical workers become construction workers.

NARRATOR: The man in charge is Sergeant First Class Renaldi
Toledo. A senior medic with 22 years' Army service under his belt, Sergeant
Toledo was just two weeks from retirement when he was mobilized to come to the
Gulf.

SERGEANT FIRST CLASS RENALDI TOLEDO: What we're doing here is we are
erecting the Emergency Medical Treatment section, very much the equivalent of a
civilian or military fixed facility emergency room. Once we get started, once
these milvans hit the ground and we crack the doors open, we have 72 hours to
receive patients.

MAJOR CHRISTOPHER NILES, M.D.: After this goes up, then we'll start
setting the operating room up, and then the nuts and bolts of the hospital will
start falling into place after that. So this is a big step for us. I mean, this
is great. We can start seeing patients soon.

NARRATOR: The operating room is in one of the containers that
folds out to form a space three times its original size.

MAJOR JOSEPH ENDRIZZI, M.D. (Urologist, 21st Combat Support
Hospital): This is our operating room suite, and there'll be two
operating room tables where we can do two surgeries simultaneously. This is all
a positive pressure environment, which means clean air is pumped into here, so
that none of this surrounding dust gets in there. It's going to be a nice,
sterile operating suite.

NARRATOR: But this is still dangerous territory. During the
night, the base comes under attack. After a sleepless night, many are trying to
recover from their first encounter with hostile fire.

FEMALE SOLDIER # 3: I'm not too worried personally, 'cause I know it's
off of the gates, and there are guards up there. I'm not worried. It'll be
dealt with.

NARRATOR: The CASH's sleeping quarters don't provide much
protection from enemy fire or from the elements.

FEMALE SOLDIER # 4: ...roughing it like we never have.

FEMALE SOLDIER # 5: They like to tell us that we're in austere
conditions, but I don't think I was really expecting it to be this bad, where
we're not even going to be able to describe to our family and friends how bad
it really is here.

FEMALE SOLDIER # 4: Mosquitoes everywhere.

FEMALE SOLDIER # 5: You can be covered up, in your sleeping bag, with
your sleeping bag over your head, the dust got in, the dirt got in, and the
mosquitoes got in.

FEMALE SOLDIER # 4: Half a mile walk to the bathroom again, in the
middle of the night with ditches everywhere...good times.

FEMALE SOLDIER: Yeah.

FEMALE SOLDIER: Yeah.

NARRATOR: All the living conditions are primitive. The
latrines are nothing more than a public hole in the ground.

MALE SOLDIER: You've got a couple of techniques. One is facing the
lumber and hanging off over the backside, and the other one is with your
backside to the lumber trying to shoot between those slats. And you can see
some people have had a little trouble with their aim.

NARRATOR: In time, the 21st will get proper latrines, showers
and laundry facilities, but creature comforts take second place. The priority
is getting the hospital ready to treat casualties.

Even the senior surgical staff help get the O.R. up and running. After 48
hours the different departments are starting to take shape. Colonel Bob Lyons
is a plastic surgeon. In times of peace, he specializes in breast
reconstruction following mastectomies; at the 21st CASH, he's the
senior physician.

COLONEL BOB LYONS, M.D. (Deputy Commander for Clinical Services):
Right now, we're in our emergency medical section tent. This is where most
of the acute injured patients will arrive. Then they'll be assessed by our, our
emergency medicine physicians and prepared for surgery if they need surgery, or
sent to the ward if they are just, uh, medical patients. This is on line with
the main line of the hospital. As you pass through this line, the next thing
you'll see is the pharmacy being set up off to our left. It's right off the
main section of the hospital that's accessible to the emergency section, the
operating room or the ward sections for whatever medications the patients may
need. We have everything a standard hospital would have. We have anesthesia, we
have surgeons, we have nurses. We have an emergency room, we have a laboratory,
we have...there is no difference for all intents and purpose.

NARRATOR: By the afternoon of the third day all that's left is
to put the finishing touches on the hospital. With just a couple of hours to go
until the 72-hour deadline, the commander of the CASH, Colonel James Bruckart,
makes a final inspection.

The last test of the hospital's readiness is the O.R. Is it prepped to
perform surgery?

COLONEL JAMES BRUCKART, M.D. (Commander, 21st Combat Support
Hospital): It even smells like an operating room, doesn't it? Aaah.
You're going to get some perhaps really sick patients come through here.

DOCTOR: What are you going to do?

COLONEL JAMES BRUCKART, M.D.: I'm going to open up 12 beds and tell them
the hospital's functioning tonight.

NARRATOR: It doesn't take long before the first serious U.S.
casualty arrives.

PRIVATE FIRST CLASS DAVID MASON: Oh! Right on the pain button!

NARRATOR: Private First Class David Mason, from the 101st
Airborne division, has broken both his ankles in a bad fall. The orthopedic
surgeon is concerned that he will face long-term disability.

COLONEL CLARK SEARLE, M.D. (Orthopedic Surgeon, 21st Combat
Support Hospital): It's a very severe injury. The top bone of the foot
is shaped as a dome with a snout that sticks off the front. And he fractured
where the snout meets the, the top portion through here.

...because thelonger this stays like this, the higher your risk
of having problems down the road. What is likely to happen once this is all
said and done, is you're probably going to have at least some achiness in both
your ankles, probably forever. So road marching and running long distances and
that sort of stuff may not be something that you're going to be able to do in
the future.

NARRATOR: David's career as a combat soldier is over. He has
to be evacuated because the CASH is not equipped to provide the complex
operations and long-term care he needs.

Anyone needing treatment taking more than a week is stabilized and
airlifted to hospitals in Europe or the U.S.

David was injured near Mosul, 160 miles to the north. With a population of
just under two million, Mosul is the third largest city in Iraq. In the months
to come, Mosul will be the site of several deadly attacks on American soldiers,
including the downing of two Blackhawk helicopters, but for now, late April,
2003, things are relatively quiet.

A forward unit of the 21st Combat Support Hospital is just outside Mosul.
Iraqis injured in the fighting over the last several weeks, who can't get
treatment in their own shattered hospitals, are now lining up at the CASH, but
only some will get in. According to Army policy, CASH units will provide
emergency care to any Iraqi who's in immediate danger of losing life, limb or
eyesight or who's been injured by American forces.

Ala, an Iraqi soldier, is a typical case: he was badly hit in both legs
during the fighting. He's come to the CASH because the local hospital cannot
treat his wounds.

MAJOR DOUGLAS PREVOST, M.D. (Orthopedic Surgeon, 21st Combat
Support Hospital): He's been treated in a hospital, apparently here in
town, for the last 28 days. That's what his father told me. They don't have any
access to medicines, they don't have any access to orthopedic instrumentation,
orthopedic hardware.

NARRATOR: Major Doug Prevost is the chief orthopedic surgeon
for the 21st CASH's Mosul unit. The son of a special forces Sergeant Major,
he's a graduate of West Point and is a father of five, himself.

MAJOR DOUGLAS PREVOST, M.D.: This is always a bit of a surprise for us.
We haven't had a chance to really see his wounds yet. This is a little bit like
opening up a Christmas package, and you really have no idea what's in there,
because it could be anything.

NARRATOR: Ala has endured three weeks without any antibiotics,
and Major Prevost soon detects that his wounds are dangerously infected.

MAJOR DOUGLAS PREVOST, M.D.: As we stand here and look at this wound, we
can smell a fairly characteristic odor of a certain type of bacteria called
"Pseudomonas," which is a fairly difficult infection to clear in these types of
injuries.

Taking care of war wounds is quite a bit different than taking care of normal
trauma that we see. Typical war wounds are much more contaminated, and they're
much more high energy, and the soft tissue is damaged to a greater extent to
what it would be if there was a car accident. So one of the things that we've
learned over the years is that to close a war injury the first time you're
there is a mistake. These wounds tend to become infected if you do that. What
we need to do is leave them open and let them drain for a long period of time,
and let them fill in on their own. Rarely do we close war injuries definitively
like we would normally. Oftentimes people want to see the skin edges back
together and everything closed, but that really is a mistake to do that.

NARRATOR: All that Major Prevost can do is clean the wounds of
all shrapnel and cut out any infected tissue. Clean conditions and antibiotics
may help control the spread of the infection. After so long without proper
treatment, the outlook for Ala is poor.

MAJOR DOUGLAS PREVOST, M.D.: He'll probably end up with amputations on
both sides below the knee.

NARRATOR: The CASH has not had to deal with the mass U.S.
casualties they'd prepared for. So far, the injuries are mostly minor: scorpion
stings...

DOCTOR: You know the scorpions here? Nobody ever dies from them.

NARRATOR: ...a variety of cuts and bruises, and several heat-related
injuries. These are the typical cases on May 1st, when President
Bush addresses the nation.

PRESIDENT GEORGE W. BUSH (President of the United States): My
fellow Americans, major combat operations in Iraq have ended. In the battle of
Iraq, the United States and our allies have prevailed.

NARRATOR: But even after May 1st, seriously injured
Iraqis continue to appear at the CASH, seeking care. In the middle of the night
a young Iraqi is brought in, critically injured by a grenade. This is the kind
of life or death combat casualty that the CASH is set up for. Shrapnel has torn
into his body. He is dying from blood loss through multiple wounds. His heart
stops before he reaches the operating room. Major Betty Kim, a cardiothoracic
surgeon, cuts his chest open and massages his heart by hand.

She gets it started; he now stands a chance. Although he's an Iraqi
soldier, the surgeons fight as hard to save him as they would an
American.

NARRATOR: It is now a race against time to find the source of
the bleeding and stem the flow.

DOCTOR: All right I've got my finger on it right now.

DOCTOR: What is it?

NARRATOR: After fifteen minutes, it's clear that major blood
vessels behind the bowel have been severed. Another surgeon, Major Yong Choi,
pinches the leaking vessels to stop the flow, but even this is not enough. The
man is hemorrhaging faster than they can squeeze plasma into him. Then his
heart stops again. As a last resort they try to shock it into action...

DOCTOR: He's dead. He's dead.

NARRATOR: ...but to no avail.

Members of the family are waiting outside.

CAPTAIN ANGELA WINN, R.N. (Emergency Room Nurse, 21st Combat
Support Hospital): The first death that I saw was very hard on me. I had
such a close relationship with the patient. This is when I was on the ward.
After that, I, I hate to say it, you kind of distance yourself a little bit,
from that, so it doesn't hurt you as much, but it does affect you every time
someone dies.

NARRATOR: After three days, the doctors' efforts have made a
remarkable difference for Ala, the young Iraqi soldier with wounded legs. The
cleaning and antibiotics have saved his limbs.

PRIVATE FIRST CLASS TORIN HOWLING WOLF (Medic, 21st Combat
Support Hospital): If he had stayed where he was in the condition he
was—personally, if I'm just going to go ahead and lay my cards on the
table—I don't think he'd have lasted another six weeks. I think he'd be
pushing up daisies.

NARRATOR: Private First Class Torin Howling Wolf is a Cherokee
who grew up in the White River Tribe, in Kansas.

PRIVATE FIRST CLASS TORIN HOWLING WOLF: The Cherokee have a really
strong tradition of training their people as warriors and healers. I mean it,
it wouldn't do any good to just run willy-nilly through the countryside,
maiming, slaughtering and killing, because we are, we are not, that's not our
goal here. Our goal here is to help an oppressed people. Our goal here is to
restore one of the most ancient and beautiful civilizations of all time.

NARRATOR: Howling Wolf and his colleagues have saved Ala's
legs and made a friend out of an enemy soldier. But Ala needs long-term
rehabilitation and further surgery. The CASH is not set up to provide this.
He'll have to be sent back into the devastated Iraqi healthcare system that has
failed him once already.

When American soldiers need long-term care, they are evacuated to U.S.
military hospitals in Europe or back home. David Mason, the Airborne private
with shattered ankles, is ready to fly out.

PRIVATE DAVID MASON: I guess I'm going to Germany, to a
hospital there. I'm going to get surgery and get screws put in, and probably go
on home. It's a good thing I'm going home, but it's a bad thing I'm not going
with my buddies. I mean, I want to go home, but I'd rather go home with all my
buddies, go through this, go through this whole war with them.

NARRATOR: David is flown down to Baghdad, where he'll be put
on a plane to Germany.

Back at the Balad Airbase, more and more wounded Iraqis, who cannot get
treatment locally, keep arriving—the issue of who the CASH will or will
not treat is becoming more acute. Among them is a fourteen-year-old girl. She
is not critically injured, but the guards on the gate took pity on her and let
her through.

CAPTAIN ANGELA WINN, R.N.: We don't know if it was unexploded ordnance
or if it was some type of powder she was playing with that...and had a big
flash, and that's what caused her burns. She's got burns on her right side of
her face, her right side of her body and on her chest.

NARRATOR: The medics aren't quite sure whether they should be
treating this girl.

MAJOR BEVERLY BEAVERS (Operations Officer, 21st Combat
Support Hospital): We have certain guidelines that we have to follow.
One of those guidelines is that she be, before she becomes a patient, she needs
to be needing to be treated for life, limb or eyesight loss. The other instance
that she would be required, for us to treat her, was if she was injured due to
something that we American soldiers had done to her. And in this particular
case, that's not what happened.

CAPTAIN ANGELA WINN, R.N.: We're going to put some bacitracin ointment
on her. And on her face, since she can't really bandage that up, we're just
going to put that on her face as a cream. We did give her some pain medication
though, before we started this treatment, because it is awfully...there are
some secondary burns which are very painful. But we're just going to do the
best we can and then send her, probably, on her way home.

PRIVATE FIRST CLASS TORIN HOWLING WOLF: If I had, you know, a magic wand
to poof...I have got, you know, all the gauze I could handle, um, sure, I would
love to be able to treat everybody, um, you know? There's only so many of these
kids, as you can see, walking around in tattered clothing and malnourished,
which you could take before you have to close your eyes and turn away from it,
or it's going to make you sick.

NARRATOR: The doctors, nurses and medics, by training and
inclination, would treat everyone, but the choice is not always theirs to make.
The Army provides guidelines, but how they're enforced on the ground is left to
the discretion of the CASH commander.

For Colonel James Bruckart, Commander of the 21st CASH, his
mission is clear.

COLONEL JAMES BRUCKART, M.D.: The primary purpose of the hospital is to
take care of our soldiers. But we will provide emergency treatment to stabilize
a local or even our enemy. But we're very selective. What we try to do is wait
for somebody who we can save their life, we can save their eyesight. Those are
the ones we think are most needing of our care.

NARRATOR: Today, officers from the Army's medical brigade,
which oversees the CASH, are on their way to the local hospital in Mosul. Iraqi
doctors are hoping that they'll approve the transfer of some injured patients
to the CASH.

MAJOR ANDREW WIESEN, M.D. (Civil-Military Affairs, 62nd
Brigade): The military can only provide care for very specific
circumstances, and those circumstances are immediate threats to life, limb or
eyesight. So, for instance, if somebody happened to have a grenade explode on
them right outin front of our gate, and we're there, well of course
we're going to take those people and stabilize them. If we were...had...some of
our troops were in action with some other people and innocent bystanders or
other soldiers from the opposing side were injured, we would take care of them
to stabilize them.

NARRATOR: The hospital has survived most of the looting
intact. Many of the doctors are highly skilled, but their expertise is useless
without supplies.

NARRATOR: In contrast, the CASH is well equipped, so the Iraqi
doctors are eager to transfer any patients that might meet the Army's
guidelines. This soldier was shot in the stomach a month ago. After multiple
operations, his wounds still have not healed.

IRAQI DOCTOR TWO: It's a difficult problem, this is a bullet, and it
passed through the body, making different problems in the body, multiple
perforations in the intestine.

NARRATOR: The doctors are worried that without clean dressing
and antibiotics, the patient will die from his infected wounds. He was shot by
Kurdish coalition fighters under the control of U.S. forces. But that doesn't
appear to be enough.

MAJOR ANDREW WIESEN: Well, there's no real connection to the U.S.
military in this case. It was the pesh merga fighters in this case, that
injured him in the first place, right?

IRAQI DOCTOR: Yeah.

MAJOR ANDREW WIESEN, M.D.: The U.S. Army doctors will probably not take
this case.

NARRATOR: In this case, injuries caused by America's allies
don't guarantee admission to a CASH. This young man has been partially
paralyzed from the neck down. He is one of Iraq's Christian minority.

MAN: The doctor say many shells affecting the neck. He say that one of
the shells is still inside 'til now.

NARRATOR: This time, it seems, U.S. forces are directly
involved. His mother says their village was bombed by American planes.

MAJOR ANDREW WIESEN, M.D.: The attackers...who were the aggressors in
that? Do we know?

MAN: Yes, U.S., U.S. rocket. She say that a bomber plane, a bomber plane
attacked the house by rocket.

MAJOR ANDREW WIESEN, M.D.: Okay. This is the same as we were talking
about, the other soldier. The U.S. military probably won't do this case, but we
can facilitate getting the non-government organizations and other government
organizations to get the appropriate equipment here.

PATIENT'S MOTHER: Thank you.

MAJOR ANDREW WIESEN, M.D.: You're welcome.

Yeah, well it's the same situation as in the beginning. They were, you know,
certainly weren't targeted as combatants, but, you know, aerial warfare, that
does happen, you know? And we try and atone for our mistakes the best we can.

NARRATOR: Even though coalition forces may have contributed to
the injuries, the medical brigade concludes that both patients are in stable
condition, so the CASH, designed primarily as a trauma center, is not the place
for them.

MAJOR ANDREW WIESEN, M.D.: The U.S. government's policy is that the most
fair and equitable way to get help to those people is not through military
sources. The military is there to provide a safe and secure environment for the
other governmental and non-governmental organizations, the humanitarian
organizations, to provide that care. Sometimes our army is funded to do
humanitarian assistance missions, but it wasn't from the military budget.
Congress really maintains control over that. And you'll see, certainly, with
the Combat Support Hospital, they really want to help. And I think these
constraints are put on us, financial constraints are put on us, because there
are many, many, many things we could do here.

COLONEL BOB LYONS, M.D.: The frustrations in who we can treat and who we
can't treat are enormous. There are many illnesses we've seen—especially
in developing a relation with the local Iraqi hospital—there are many
situations that are easy for us to treat. Many situations they confront in
their hospital that we could treat easily in this hospital, yet I cannot use
these resources to affect those changes. That's very frustrating.

NARRATOR: But when two young Iraqis arrive with life
threatening burns from exploded ordnance, there are no questions asked. They're
in good hands: Colonel Bob Lyons is the chief plastic surgeon at Brook Army
Medical Center in San Antonio, home to the military's only specialized burn
unit.

COLONEL BOB LYONS, M.D.: This young man is burned more seriously than
the other, with 60 percent total body surface area burns. We calculate those
surface areas because it helps us with managing their fluid requirements. We
debride off all this dead skin so ourantibiotic ointments can help
protect the wounds from getting infected. As you can see, his face is all
debrided right now. You can see his legs are all debrided of the dead skin. In
America or Britain, the prognosis for this guy would be very good. He may need
skin grafting of these feet, but he would get aggressive burn treatment and
physical therapy.

NARRATOR: But that won't happen here. There's no
fully-functioning burn unit in all of Iraq, even at the CASH. After cleaning
him up and giving him antibiotics, all the doctors can do for the patient is
try to ease his pain.

MAJOR CHRISTOPHER NILES, M.D.: He is extremely critical. These burn
patients have a tough time. They have a lot of, a lot of issues going on with
thermal regulation, their temperature, their fluids in their bodies. It's a
huge shock to them and he's, he's extremely critical right now

NARRATOR: To keep the patient completely still, the doctors
would like to use a paralytic agent called "vercuronium," but it's in short
supply.

COLONEL BOB LYONS, M.D.: We have a dying patient in there now. I have a
certain amount of a certain drug that I can't consume on him because I have to
be able to operate. So I had to make the decision that we don't use that drug
on him. We'll use other drugs, maybe not as effective, but I have to be able to
save other people's lives. I have to make those decisions for the other
physicians. That's my job.

NARRATOR: Three days later the badly burnt young man
dies.

Most Iraqis seeking treatment at the CASH are soldiers wounded by U.S.
forces. But others are civilians hurt in accidents, some by unexploded ordnance
or simply sick. The ethical dilemmas this produces are troubling the
doctors.

MAJOR CHRISTOPHER NILES, M.D.: We raced up here with not, really, a true
mission. Obviously we're going to take care of our troops as best we can. But
then, after that, what do we do? What's our mission? Is it humanitarian? Is it
not? It's been very frustrating because we have local Iraqis coming to the
front gate asking for us to help them, and us not being able to give it.

NARRATOR: Some of the doctors are asked to be gatekeepers, to
judge who gets treatment and who doesn't. Major Nhat Nguyen-Minh, a general
surgeon who escaped Vietnam to come to America in 1978, goes to the front gate
to assess a patient.

MAJOR NHAT NGUYEN-MINH, M.D. (General Surgeon, 21st Combat
Support Hospital): We are going to one of the gates. Apparently there's
a, a two-year-old child that's coming in, that she has some type of burns. They
say it's a second degree or a third degree burns over her...

SOLDIER: Apparently they went to the one in Baghdad, and they told them
they couldn't be there, because there was some kind of virus or some stuff.

MAJOR NHAT NGUYEN-MINH, M.D.: Yeah, so they need to go to the Balad
hospital, Balad Hospital.

MALE SOLDIER: They need to go to the Balad.

MAJOR NHAT NGUYEN-MINH, M.D.: We cannot take...I'm sorry, we cannot take
care of her here.

You know, there's a lot of emotion involved in that. You know, you see a
little child, you don't want to be leaving her. You know that most likely she
won't, she won't, get the medical care that she will get like she will here out
in the Balad or any local hospital. So you would like to take care of her, but
she doesn't meet the criteria. And if we are going to start bringing these,
these in, we are going to be...they are going to...everybody around this area
is going be bringing them in. And we're going to end up taking care of all
these local Iraqis, and then we won't...you know, we'll soon be running out of
the resources to take care of our own soldiers.

MAJOR BEVERLY BEAVERS: What happened?

MAJOR NHAT NGUYEN-MINH, M.D.: No, we, we saw them, and we sent them
away. We told them to go to the Balad hospital.

MAJOR CHRISTOPHER NILES, M.D.: Who do we let in the gate? Literally and
figuratively? Do we let this child but not this child or these adults? And so
it's been very frustrating for those who've had to go out to the gate and look
at a patient, look them in the eye and say, "No, we can't help you," and send
them away. I think it sends a mixed message to the Iraqis. We're here to help
them and make them better, and yet we turn them away.

NARRATOR: While Major Niles struggles over how the resources
of the CASH are deployed, another fully equipped American hospital is sitting,
unused, in the Kuwaiti desert. Weeks after arriving in the Gulf, Colonel
Powell's 10th CASH is still waiting for a mission. Colonel Lounsbury hasn't
treated a single combat casualty.

COLONEL DAVID LOUNSBURY, M.D.: There's a humanitarian disaster of some
sort going on north of here and no one attending them. The hospitals are full,
and the care is inadequate, and it makes me feel terrible. I think we have a
role to play. I think we could do it, do it well and do it effectively, do it
efficiently. And we could relieve some of that agony and suffering. For God's
sakes, let us be part of that experience. Let us be part of taking care of
those people.

SERGEANT CHRISTIAN RAMIREZ: We want to get up there, set up, start
treating. We went from a combat mission to a humanitarian mission. Hey, you
know, either way, we're doing our job. You know, we're all ready. Everybody's
ready to go do it.

NARRATOR: The staff of the 10th CASH were never given the
humanitarian mission they craved. After four months in Kuwait, the 10th Combat
Support Hospital will be sent back to Colorado, though some staff and supplies
will go to Iraq.

Back at the 21st, the life, limb and eyesight policy has allowed the CASH
to admit Najla. Her mother says the eight-year-old was injured when a U.S.
missile blew up an Iraqi tank. Najla was trapped at home for several weeks, her
family too scared by the fighting to venture out. Now, on top of her original
injuries, she's severely malnourished. She's in such bad condition, the doctors
appeal for help from back home, and the University of Michigan Trauma Burn
Center agrees to take Najla.

MAJOR CHRISTOPHER NILES, M.D.: If we can get her back home to the
States, they will be able to get some big I.V.s in her and start getting her
fed and getting her better. So I think her only hope right now is to get her
back to the States and get her taken care of.

NARRATOR: It's a challenge to help Najla in a combat hospital
equipped to treat soldiers, not children, but no one wants to back away from
this case.

MAJOR CHRISTOPHER NILES, M.D.: It's hard. It makes you feel bad. It
makes you go home and say your prayers and thank God that your kids are okay.
I've got two little girls at home, and I see her and her parents, and it breaks
my heart. It's terrible. So it's, I guess, a little extra motivation to try and
do the right thing.

NARRATOR: A plane is due in the following day to take Najla to
America. If Major Niles can get her stabilized overnight, she will get the best
care in the world.

Seeing the conditions endured by children like Najla is starting to affect
many in the CASH.

SERGEANT FIRST CLASS GLENN PAULINO: We come over here and we see what
they don't have, and we think about where we came from, where we live, how we
live. And then we think about all the stuff that we take for granted back home.
And there's a lesson learned for a lot of us. And I bet you that when we go
back home, a lot of the stuff that we take for granted...we're going to just
stop and smell the roses every now and then.

NARRATOR: The next morning, Najla is getting worse. Major
Niles and the team are now struggling to get her ready for her flight to
America.

MAJOR CHRISTOPHER NILES, M.D.: What do we know about her flight home, do
we have any information about it?

DOCTOR: Got an update. Colonel Sigmen is on the phone right now.

NARRATOR: There's a medevac plane on its way, but Major Niles
is worried Najla may be too ill to travel. Her extreme malnourishment could
lead to complete organ failure.

MAJOR CHRISTOPHER NILES, M.D.: Right now, we're just trying to see if we
can keep her well enough to send her back to the States. The University of
Michigan has accepted her, um, and we just need to make sure we get her taken
care of and set to go, so we can get her home and get her taken care of.

Okay, Princess. Oh God, help us.

NARRATOR: With no time to lose, Major Niles asks for blood
tests to ensure that Najla will survive the trip.

MAJOR CHRISTOPHER NILES, M.D.: How much do you think you need?

WOMAN: I don't know.

MAJOR CHRISTOPHER NILES, M.D.: Let me take it all with me. Can you hold
on here? And let me run down to the lab real quick and...I want to make sure I
can get what I want, all right? Here's the deal.

NARRATOR: He asks the lab to test for electrolite levels to
check her metabolic condition and for arterial blood gases to see if she'll be
able to breathe unassisted on the plane.

MAJOR CHRISTOPHER NILES, M.D.: Bonnie, I'm going to run down and see if
I can get this, would you mind waiting here and bringing this down to me?

MAN: No problem.

MAJOR CHRISTOPHER NILES: Thank you, appreciate it.

NARRATOR: When he comes back to the intensive care ward, it's
too late.

WOMAN: I can't take these children coming in, man.

WOMAN: This is the hard part.

MAJOR CHRISTOPHER NILES, M.D.: This is why I don't do peds. There's no
way.

WOMAN: No more.

WOMAN: Do we have anyone to sit with her?

MAJOR CHRISTOPHER NILES, M.D.: Can we, can we get a couple of screens or
little curtains that we have? Maybe ask Debbieat one of the wards, and
just give Mom some privacy? Just at least around here, so the whole world's
not...

We did everything we could.

MAN: Yeah.

MAJOR CHRISTOPHER NILES, M.D.: I know. It's never easy though. She was,
you know, as we suspected, very sick, and kids have a pretty good reserve. They
can go for quite a while 'til they hit the edge of the cliff. And she just
fought as long as she could. She was a fighter, and she did very well for how
sick she was. Not a good day to be a doctor. Not here.

NARRATOR: After NOVA left Iraq in May, 2003, attacks on
American soldiers increased dramatically, and the wounded flooded the Combat
Support Hospitals in the region. Since they opened their doors, the two units
of the 21st have treated more than 30,000 patients.

At the same time, the 21st CASH has been working closely with
local Iraqi hospitals, where conditions are gradually improving after the
devastating effects of sanctions, Saddam and the war.

Many CASH personnel appearing in this program remain on active duty in
Iraq, while others have returned home. On NOVA's Web site, hear from several
CASH members on what's happened to them since they were filmed. Find it on
PBS.org.

National corporate funding for NOVA is provided by Cancer Treatment Centers of America.
Major funding for NOVA is provided by the David H. Koch Fund for Science, the Corporation for Public Broadcasting, and PBS viewers.